Aortic Endograft Infection: Diagnosis and Management

Abstract

Aortic endograft infection (AEI) is a rare but life-threatening complication of endovascular aneurysm repair (EVAR). The clinical features of AEI range from generalized weakness and mild fever to fatal aortic rupture or sepsis. The diagnosis of AEI usually depends on clinical manifestations, laboratory tests, and imaging studies. Management of Aortic Graft Infection Collaboration (MAGIC) criteria are often used to diagnose AEI. Surgical removal of the infected endograft, restoration of aortic blood flow, and antimicrobial therapy are the main components of AEI treatment. After removing an infected endograft, in situ aortic reconstruction is often performed instead of an extra-anatomic bypass. Various biological and prosthetic aortic grafts have been used in aortic reconstruction to avoid reinfection, rupture, or occlusion. Each type of graft has its own merits and disadvantages. In patients with an unacceptably high surgical risk and no evidence of an aortic fistula, conservative treatment can be an alternative. Treatment results are determined by bacterial virulence, patient status, including the presence of an aortic fistula, and hospital factors. Considering the severity of this condition, the best strategy is prevention. When encountering a patient with AEI, current practice emphasizes a multidisciplinary team approach to achieve an optimal outcome.

Keywords: Abdominal aortic aneurysm; Diagnosis; Endovascular aneurysm repair; Infections; Treatment.

Fig. 1

Serial computed tomography (CT) images showed the development of aortic endograft infection and pseudoaneurysm at the site of the suprarenal fixing barb in a patient who underwent endovascular aneurysm repair (EVAR) at another hospital. Upon history taking, the patient received antibiotic treatment for 3 weeks due to fever before EVAR. (A) CT at 1 month after EVAR showed no evidence of infection. (B) Seven months after EVAR, fever developed and CT showed a retroperitoneal fluid collection (arrow) around the suprarenal fixing device. (C) After 1 month of antibiotic therapy, follow-up CT showed increased fluid collection (arrow). (D) Follow-up CT a week later showed a saccular aneurysm (arrow) with fluid collection at the level of the left renal vein.

Fig. 2

¹⁸F fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET CT) in a patient with aortic endograft infection after endovascular aneurysm repair showed FDG uptake around the aortic endograft and urinary tracts.

Fig. 3

The syringe technique is used for removal of the aortic endograft. Pushing the syringe into the aorta allowed the suprarenal fixing struts to converge into the syringe. Note that the cut edge of the syringe was smoothened to avoid aortic wall injury during the procedure.

Fig. 4

The images showed a cryopreserved allograft. (A) After thawing the frozen grafts, a composite bifurcated graft was made at the back table with 2 segments of iliac and one aortic allograft. (B) In situ aorto-iliac reconstruction with the cryopreserved allograft was performed for a patient with aortic endograft infection. (C) In situ aortic reconstruction with cryopreserved allograft was again performed in another patient. (D) The allograft was covered with mobilized omentum after completion of the aorto-iliac reconstruction.

Fig. 5

Image showed patient survival rates according to the graft material after in situ aortic reconstruction for patients with aortic endograft infection. Adapted from the article of Smeds et al. (J Vasc Surg 2016;63:332-340) [10] with original copyright holder’s permission.

Fig. 6

Flow chart showed the suggested treatment algorithm for patients with aortic endograft infection.